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1 Journal of the Korean Dysphagia Society 2011;1:25-30 Review Ariticle 도구를이용한연하검사 김덕용ㆍ정수진 연세대학교의과대학재활의학교실및연구소 Instrumental Assessment of Swallowing Deog Young Kim, M.D., Ph.D., Soo Jin Jung, M.D., Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea Swallowing difficulty is common, especially in the elderly, neurologic disorders, head & neck cancer and etc. It may cause dehydration, weight loss, malnutrition, and aspiration pneumonia. The bedside examination may be important to assess the swallowing difficulty. However, the instrumental assessments such as videofluoroscopic swallowing study, fiberoptic endoscopic examination of swallowing, dynamic CT and manometry are more informative to identify the pathophysiology of dysphagia and are also more helpful to make the therapeutic plans. The unique characteristics of each instrumental assessment of swallowing were reviewed. (JKDS 2011;1:25-30) Keywords: Swallowing, Dysphagia, Assessment, Videofluoroscopic swallowing study 서론 연하곤란은먹는즐거움을잃게할뿐만아니라, 탈수, 흡인성폐렴이나영양실조와같은심한부작용을초래하고나아가사망에이르게하는심각한문제이다. 연하곤란은 50 대이상에서 15-22% 로보고되고있으며 1, 단기입원환자의 12-13%, 장기요양시설환자의 60% 이상으로보고되고있다 2. 뇌졸중. 뇌손상, 파킨씨병, 두경부암환자의경우 20-50% 정도에서발생한다 3-6. 이러한연하곤란의원인및흡인여부를정확히평가하는것은연하곤란환자의치료전략을수립하는데매우필수적이다. 연하과정을평가하기위해임상적인침상검사가가능하지만, 구강기, 인두기, 식두기에서일어나는일련의연하과정을평가장비없이육안으로관찰할수없다는점에서여러 가지장비를이용한평가방법들이개발되었다. 현재까지소개되어이용되고있는방법은비디오연하조영촬영 (videofluroscopic swallowing assessment), 내시경적연하검사 (fiberoptic endoscopic evaluation of swallowing), 컴퓨터단층촬영 (computed tomography), 초음파 (ultrasonography), 신티그래프 (scintigraphy), 압력검사 (manometry) 등이있다. 본고에서는이와같은여러가지검사방법의원리를간략히소개하고, 임상적측면에서장단점을비교해보아연하곤란환자의평가에도움을주고자한다. 본론 1. 비디오연하조영촬영 비디오연하조영촬영은조영제를첨가한음식을실제 투고일 : 2010 년 12 월 15 일, 심사일 : 2010 년 12 월 20 일, 게재확정일 : 2011 년 1 월 3 일책임저자 : 김덕용, 서울시서대문구신촌동 134 번지 ( ) 신촌세브란스병원재활의학과 Tel: 02) , Fax: 02) kimdy@yuhs.ac Copyrights c The Korean Dysphagia Society,

2 26 Deog Young Kim, Soo Jin Jung:Instrumental Assessment of Swallowing Fig. 1. Normal finding of videofluroscopic swallowing study. 로먹도록하면서그때구강기 (oral phase), 인두기 (pharyngeal phase), 식도기 (esophageal phase) 에서의움직임및조화를보고, 음식의흡인 (aspiration) 여부를판단하는것으로현재연하장애의평가중가장많이이용되고, 유용한방법으로현재표준검사법이다 7.(Fig. 1.) 비디오연하촬영을시행하기위해서는실시간방사선촬영이가능한 fluoroscopy 가필요하고, 연하과정이수초이내에일어나는과정이므로이를분석하기위해서는실시간녹화가가능한 real time video recorder 가필요하다. 비디오연하촬영은환자를방사선투시판과방사선발생기사이에앉은상태에서피검자가조영제가섞인음식물을삼키는동안의연하과정을실시간으로보는동시에녹화를한다. 일반적으로측면에서의촬영을주로하고, 경우에따라전후면촬영을추가하여시행한다. 연하과정은음식물의성상에따라다르게나타나므로여러가지종류의음식물을바륨과섞어시도하는데, 일반적으로는음식물이없는상태에서삼켜보도록하고, 쿠키와같은딱딱한음식물, 점도를달리한진한액체 (thick liquid), 연한액체 (thin liquid) 등을시도한다 7. 비디오연하조영촬영은단순히흡인여부만을판단하는검사가아니고, 침상검사에서는관찰할수없는구강기, 인두기, 초기식도기에서의연하과정동안의해부학적또는기능적인이상소견을관찰할수있고, 또한음식물의점도를달리하거나, 알려진여러가지보상기법하에서삼킴을시도하여가장안전하고, 효과적인삼킴조건을정할수있다 비디오연하조영촬영은육안으로시공간적인필수요소를확인할수있고, 침상검사에서확인할수없는무증상흡인 (silent aspiration) 을발견할수있다는점에서침상검사에비해임상적의의가있다. 비디오연하조영촬영을시행한 2,000 명의환자중전체흡 인의 55% 가무증상흡인이라는보고를참조해볼때연하곤란으로인한흡인이의심되는경우평가에있어비디오연하조영촬영검사는매우중요함을알수있다 11. 비디오연하조영검사를통해구강기에서는입순닫힘 (labial closure), 혀의움직임 (tongue movement), 외측회담힘 (seal off of lateral sulcus), 식괴의후방이동 (posterior propelling of bolus) 등을평가할수있고, 인두기에서는연하반사 (swallowing reflex) 의지연여부, velopharyngeal port 의닫힘, 인두연동작용 (pharyngeal peristalsis), 후두거상 (laryngeal elevation), 후두닫힘 (laryngeal closure) 등을평가할수있고, 식도기에서는윤상인두근부전 (cricopharyngeal dysfunction) 여부를확인할수있다. 또한본검사는식괴의관통 (penetration) 및흡인 (aspiration) 등을평가할수있다 7. 보통흡인은연하반사를기준으로연하전, 연하중, 연하후흡인으로나누어평가하게되는데, 연하전흡인은구강조절부전이나연하반사지연에의해주로일어나는것이고, 연하중흡인은후두방어기전의문제로인해주로일어나며, 연하후흡인은후두개계곡 (valleculae) 이나이상와 (pyriform sinus) 에남아있던잔여물이나윤상인두근부전으로인해주로일어난다. 비디오연하조영촬영은상기기술한대로각연하단계의복잡한과정을육안으로확인할수있고, 해부학적구조와각구조의동적움직임을평가할수있으며, 흡인의원인을알아낼수있고, 자세, 음식물의종류, 여러가지보상기법에따른변화를평가할수있어연하장애의치료적전략을수립하는데많은도움을준다는장점이있는반면에방사선에노출되고, 검사과정중에흡인이일어나폐렴이발생할수있다는단점과피검자가앉은자세를유지할수있는능력이있어야하고, 협조적이어야하고, 검사를시행하고분석하는데있어잘훈련된인력이필요하다는단점이있다 12. 하지만최근연구에의하면비디오연하조영촬영술은방사선노출의위험이있지만, 다른방사선검사와비교하여도위험한수준은아닌것으로밝혀졌다 13. 또한촬영중흡인되는바륨도비교적안전한것으로보고되고있다. 최근들어비디오연하조영촬영소견을정량화하려는많은시도들이되고있는데, 크게두가지접근법이있다. 첫번째는검사를통해얻은소견을점수화하려는시도이고, 두번째는연하관저에서보여주는여러가지시공간적지표를정량화하려는시도이다. 첫번째접근법의대표적인지표는기능적연하척도 (functional dysphagia scale) 와투과 - 흡인척도 (penetration-aspiration scale) 이

3 김덕용ㆍ정수진 : 도구를이용한연하검사 27 Table 1. Functional dysphagia scale. Factor Coded Value Score Fig. 2. Quantitative measurement of hyoid bone movement. 다. 기능적연하척도는구강기부터식도기까지의연하과정의각각의주요요소들을구하고, 연하장애의정도및흡인의예측지표로쓰기위해개발한것으로간편하고, 이용하기쉽다는장점이있다 14.(Table 1) 투과 - 흡인척도는투과와흡인을세분화하여점수화한것으로검사자간, 검사자내신뢰도가매우높아흡인정도를측정하는데가장많이이용되는척도이다 15.(Table 2) 두번째시공간적지표의정량화하려는접근은컴퓨터를이용하여비디오를분석할수있는기술이발전하면서활발한연구가진행되고있다 16,17.(Fig. 2.) 대표적인시간적지표로는구강통과시간 (oral transit time), 인두통과시간 (pharyngeal transit time), 인두지연시간 (pharyngeal delay time) 등이있고, 공간적지표로는설골 (hyoid bone) 및후두융기 (laryngeal prominence) 의움직임, 연두개 (epiglottis) 의움직임등이있다. 이러한시공간적지표는아직정상인표준치가완전히정립되지않은문제점은있으나, 중재나치료전후를비교하는데유용하다. 2. 광섬유내시경적연하검사 (fiberoptic endoscopic evaluation of swallowing) 광섬유내시경적연하검사는 Langmore 등 18 에의해처음소개된방법으로비강을통해내시경을삽입하여비강인두 (nasopahrynx), 구강인두 (oropharynx) 및후두상방의해부학적구조의이상을살펴보고, 음식물을삼키도록하여직접육안으로연하전후의변화를관찰하는방법이다 19.(Fig. 3.) 본검사를시행하기위해서는유연비인두내시경 (flexible nasolaryngoscope), 비디오카메라와녹화기, 검사식이필 Lip Closure Infact 0 10 Inadequate 5 None 10 Bolus formation Infact 0 6 Inadequate 3 None 6 Residue in oral cavity None % % 4 50% 6 Oral tansit time 1.5s 0 6 >1.5s 6 Triggering of pharyngeal swallow Normal 0 10 Delayed 10 Larynegal elevation and epiglottic Normal 0 12 closure Reduced 12 Nasal Penetation None % % 8 50% 12 Residue in valleculae Dagger None % % 8 50% 12 Residue in pyriform sinuses None % % 8 >50% 12 Coating of pharyngeal wall after No 0 10 swallow Yes 10 Pharyngeal transit time 1.0s 0 4 >1.0s 4 Total 100 요하다. 광섬유내시경은음식물의종류를달리하거나보상전략의효과를직접알아보기위해이용되기도하고, 최근들어서는감각검사 (fiberoptic endoscopic evaluation of swallowing with sensory test; FEESST) 를하여인두감각을정량적으로측정할수있다 20. 감각검사는모뿔 - 후두덮개주름 (aryepiglottic fold) 에일정한공기압력을불어넣어후두내전반사 (laryngeal adduction reflex; LAR) 를유발여부를확인하는것으로, 일반적으로 6 mmhg 이상의공기압력에반응이없는경우기도흡인이나흡인성폐렴이발생할

28 Deog Young Kim, Soo Jin Jung:Instrumental Assessment of Swallowing Table 2. Penetration-aspiration scale. 1. Material does not enter the airway 2.

4 28 Deog Young Kim, Soo Jin Jung:Instrumental Assessment of Swallowing Table 2. Penetration-aspiration scale. 1. Material does not enter the airway 2. Material enters the airway, remains above the vocal folds, and is ejected from the airway 3. Material enters the airway, remains above the vocal folds, and is not ejected from the airway 4. Material enters the airway, contacts the vocal folds, and is ejected from the airway 5. Material enters the airway, contacts the vocal folds, and is not ejected from the airway 6. Material enters the airway, passes below the vocal folds and is ejected into the larynx or out of the airway 7. Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort 8. Marerial enters the airway, passes below the vocal folds, and no effort is made to eject 구조를직접육안으로관찰할수있고, 흡인이나삼킴후후두의잔여물및침고임을살펴보는데유용하다는장점이있다 23. 하지만구강이나식도를관찰할수없고, 연하과정중인두기에서상부식도열림, 후두거상, 인두의연동을관찰하기어렵고, 특히삼킴순간에인두수축근의수축과후두덮개가닫히면서보이지않게되는시야상실 (white out) 이나타나는문제점이있고, 연하장애의기전을밝히는데는어렵고, 불편감이있는경우가있고 24, 검사를하기위해서는숙련된전문가가필요하다는단점이있다 12. 부작용으로구역질, 실신, 후두경련, 비출혈등이있을수있으나그발생가능성은매우드물며안전한검사로알려졌다 광섬유내시경적연하검사는비디오연하조영촬영과더불어임상적으로매우유용한검사이며, 서로보완적인측면을고려해야시행해야할것이다 컴퓨터단층촬영 (computed tomography) Fig. 3. Fiberoptic endoscopic evaluation of swallowing (by permission of Se Hee Jung, M.D.). 가능성이높은것으로알려져있다 21. 광섬유내시경적연하검사는비디오연하조영촬영과비교하여흡인에대한민감도는더높다 22. 침상에서누운자세에서도검사가가능하여앉는자세를취할수없거나, 의식저하로인해협조가잘되지않거나, 환자가침상에서벗어나이동하기어려운경우와같이비디오연하조영촬영이불가능한경우에유용하며, 두경부암수술후나방사선치료후구조적변화를살펴보는데매우우수하고, 소아의경우방사선노출이전혀없고, 비디오연하조영촬영술을시행하는데협조적이지않은경우가많아고려해볼수있는검사법이다. 광섬유내시경적연하검사는방사선노출이전혀없고, 기기의이동성이좋고, 바륨이섞이지않은실제음식을시도해볼수있고, 성대의움직임, 흡인, 관련해부학적 컴퓨터단층촬영은삼킴과관련된여러해부학적구조를확인하기위해주로사용되어왔으나, 기술의발전으로초당 10 프레임이상일정부위를촬영할수있는 area detection CT 가개발되면서삼킴동안의동적움직임을삼차원으로재구성하여연하장애를평가하려는시도가있다. 이러한동적컴퓨터단층촬영은고해상도로연하와관련된해부학적구조의시공간적변화및조화를보다정확하게측정할수있어연하생리연구에많은도움을줄수있다 하지만, 고가의장비를이용해야하고, 방사선노출이위험이있다는점에서한계가있어아직임상적적용은어려운상태이다 초음파연하검사 (ultrasonography) 초음파연하검사는비디오연하조영촬영에서방사선을이용하는것과는달리초음파를이용하는것으로비디오연하조영촬영에서는볼수없는연부조직의구조를잘관찰할수있고, 방사선의노출이없고, 이동이자유롭고, 구강기의움직임을잘관찰할수있다. 하지만연하과정중인두기과정및흡인여부를정확히관찰하기가어렵고, 해상도가떨어지고, 검사자의숙련도에의해검사결과가영향을많이받는다는단점이있어현재잘이용되지않고있다 신티그래피 (scintigraphy) 감마카메라를이용하여동위원소가포함된식이를섭취후음식물의각단계별통과시간, 통과량을측정할수있고, 위식도역류여부를측정할수있으며, 폐로의흡인

5 김덕용ㆍ정수진 : 도구를이용한연하검사 29 여부를측정할수있다는장점이있으나, 비디오연하조영촬영에비해해상도가떨어지고, 연하와관련된해부학적구조와의관계를알수없어, 흡인및연하장애의원인을알아보는데무리가있다. 이러한점에서비디오연하조영촬영의보완적인검사로이용할수있다. 그러나동위원소를식이에섞지않고입에주입한후폐로의타액흡인여부, 흡인정도및흡인된동위원소의제거정도를알아보아식이로인한흡인이아닌타액으로인한흡인여부를알아보는데유용한검사로이용된다. 6. 인두및식도압력검사 (pharyngeal and upper esophageal manometry) 압력검사는압력센서를삽입한후일반적으로식도부위의압력을측정하여식도기에서의연동운동이나윤상인두근의이완 / 수축정도를측정하는데주로이용되고있고, 최근들어인두부압력을측정하는데도일부이용되고있고, 특히인두수축근의약화나윤상인두근의이완이잘되지않는경우연하장애평가에도움이된다 30. 하지만압력센서의위치를잘고정하는데여려움이있다는단점이있다. 결론 연하장애를평가하기위한여러가지검사법들이많이소개되고있다. 각검사마다고유의특성과장단점이있으므로, 연하장애를평가할때이러한특성을잘이해하고접근한다면연하장애상태와원인을정확히이해하고, 이를치료에응용할수있을것으로생각된다. REFERENCES 1. Lindgren S, Janzon L. Prevalence of swallowing complaints and clinical findings among year-old men and women in an urban population. Dysphagia. 1991;6: Siebens H, Trupe E, Siebens A, Cook F, Anshen S, Hanauer R, et al. Correlates and consequences of eating dependency in institutionalized elderly. J Am Geriatr Soc. 1986;34: Gordon C, Hewer RL, Wade DT. Dysphagia in acute stroke. Br Med J (Clin Res Ed). 1987;295: Horner J, Massey EW, Riski JE, Lathrop DL, Chase KN. Aspiration following stroke: clinical correlates and outcome. Neurol. 1988;38: Logemann JA, Blonsky ER, Boshes B. Dysphagia in parkinsonism. JAMA. 1975;231: Larsson M, Hedelin B, Johansson I, Athlin E. Eating problems and weight loss for patients with head and neck cancer: a chart review from diagnosis until one year after treatment. Cancer Nurs. 2005;28: Palmer JB, Kuhlemeier KV, Tippett DC, Lynch C. A protocol for the videofluorographic swallowing study. Dysphagia. 1993;8: Leslie P, Carding PN, Wilson JA. Investigation and management of chronic dysphagia. BMJ. 2003;326: Raut VV, McKee GJ, Johnston BT. Effect of bolus consistency on swallowing--does altering consistency help? Eur Arch Otorhinolaryngol. 2001;258: Shanahan TK, Logemann JA, Rademaker AW, Pauloski BR, Kahrilas PJ. Chin-down posture effect on aspiration in dysphagic patients. Arch Phys Med Rehabil. 1993;74: Garon BR, Sierzant T, Ormiston C. Silent aspiration: results of 2,000 video fluoroscopic evaluations. J Neurosci Nurs. 2009;41: Palmer J, Monahan D, Matsuo K. Rehabilitation of patients with swallowing disorders. In: Braddom R, ed. Physical medicine & rehabilitation. 3rd ed. Philadelphia: Saunders Elsevier; 2007: Zammit-Maempel I, Chapple CL, Leslie P. Radiation dose in videofluoroscopic swallow studies. Dysphagia. 2007; 22: Han TR, Paik NJ, Park JW. Quantifying swallowing function after stroke: a functional dysphagia scale based on videofluoroscopic studies. Arch Phys Med Rehabil. 2001; 82: Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11: Logemann JA, Pauloski BR, Rademaker AW, Kahrilas PJ. Oropharyngeal swallow in younger and older women: videofluoroscopic analysis. J Speech Lang Hear Res. 2002; 45: Paik NJ, Kim SJ, Lee HJ, Jeon JY, Lim JY, Han TR. Movement of the hyoid bone and the epiglottis during swallowing in patients with dysphagia from different etiologies. J Electromyogr Kinesiol. 2008;18: Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia. 1988;2: Kidder TM, Langmore SE, Martin BJ. Indications and techniques of endoscopy in evaluation of cervical dysphagia: comparison with radiographic techniques. Dysphagia. 1994;9: Aviv JE, Kim T, Sacco RL, Kaplan S, Goodhart K, Diamond B, et al. FEESST: a new bedside endoscopic test of the motor and sensory components of swallowing. Ann Otol Rhinol Laryngol. 1998;107: Aviv JE, Spitzer J, Cohen M, Ma G, Belafsky P, Close LG. Laryngeal adductor reflex and pharyngeal squeeze as predictors of laryngeal penetration and aspiration. Laryngoscope. 2002;112: Leder SB, Sasaki CT, Burrell MI. Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia. 1998;13:19-21.

6 30 Deog Young Kim, Soo Jin Jung:Instrumental Assessment of Swallowing 23. Kelly AM, Leslie P, Beale T, Payten C, Drinnan MJ. Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: does examination type influence perception of pharyngeal residue severity? Clin Otolaryngol. 2006;31: Warnecke T, Teismann I, Oelenberg S, Hamacher C, Ringelstein EB, Schabitz WR, et al. The safety of fiberoptic endoscopic evaluation of swallowing in acute stroke patients. Stroke. 2009;40: Aviv JE, Murry T, Zschommler A, Cohen M, Gartner C. Flexible endoscopic evaluation of swallowing with sensory testing: patient characteristics and analysis of safety in 1,340 consecutive examinations. Ann Otol Rhinol Laryngol. 2005;114: Cohen MA, Setzen M, Perlman PW, Ditkoff M, Mattucci KF, Guss J. The safety of flexible endoscopic evaluation of swallowing with sensory testing in an outpatient otolaryngology setting. Laryngoscope. 2003;113: Wu CH, Hsiao TY, Chen JC, Chang YC, Lee SY. Evaluation of swallowing safety with fiberoptic endoscope: comparison with videofluoroscopic technique. Laryngoscope. 1997;107: Inamoto Y, Fujii N, Saitoh E, Baba M, Okada S, Katada K, et al. Evaluation of swallowing using 320-detectorrow multislice ct. Part II: kinematic analysis of laryngeal closure during normal swallowing. Dysphagia (in press). 29. Fujii N, Inamoto Y, Saitoh E, Baba M, Okada S, Yoshioka S, et al. Evaluation of swallowing using 320- detector-row multislice ct. Part I: single- and multiphase volume scanning for three-dimensional morphological and kinematic analysis. Dysphagia (in press). 30. Hila A, Castell JA, Castell DO. Pharyngeal and upper esophageal sphincter manometry in the evaluation of dysphagia. J Clin Gastroenterol. 2001;33:

방사선학회 회장단 및 분과위원장

방사선학회 회장단 및 분과위원장 Myoyoung Jung, Namgil Choi, Jaebok Han, Jongnam Song, Weonjin Kim Dept. of Radiology, Dongshin University, Dept. of Occupational Therapy, Dongshin University 정묘영, 최남길, 한재복, 송종남, 김원진 동신대학교방사선학과, 동신대학교작업치료학과